Ortho Notes 2

8/8/2019 Ortho Notes 2

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2nd ShiftingMS 1 PT4B

Hip

AVN OF THE FEMORAL HEAD Generalities:

Avascular necrosis or osteonecrosis Due to impairment of blood supply Etiology:

Trauma e.g., femoral neck fracture Small vessel blockage Fat embolism Coagulopathy

Pathology: Death of tissue Healing response

Resorption of dead bone Laying down of new bone Creeping substitution

Weakness of the area predisposes to collapse Pathogenesis

V vascular (sickle cell, pregnancy) In infection (septic emboli) D drugs / toxins (steroid, alcohol) I inflammatory (pancreatitis) C congenital (Gauchers disease) A autoimmune (SLE, RA) T trauma (fracture, dislocation, Caisson) E endorine / metabolic (Cushing)

Clinical features: Pain over the inguinal area

Worse with weight bearing Muscle spasm

Limitation of motion Radiographs:

Crescent sign due to subchondral collapse Loss of sphericity of the head Areas of increased density of the head Collapse of the femoral head

Treatment: Surgical treatment

Core decompression Vascularized bone grafting Corrective osteotomy Arthrodesis Hemiarthroplasty

Total joint replacement DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) Abnormal development or dislocation sec to capsular laxity & mechl factors Left hip (67%)

Risk factors: Breech & inc maternal estrogen (30-50%) Female (85%) Family hx (20%+) First born

Potential obstruction


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Iliopsoas Pulvinar Contracted inferomedial hip capsule Transverse acetabular ligament

Teratologic form Pseudoacetabulum at or near birth Arthrogryposis or Larsens Immediate surgery

Diagnosis Ortolani reduce Barlow dislocate Galeazzi sign foreshortening of femur Asymmetric gluteal folds (+) Trendelenburg stance

Treatment Options Open reduction

12-18 months old Failed closed reduction (+) obstructive limbus Unstable safe zone Capsulorrhaphy Adductor tenotomy Femoral shortening Initial tx for >18 months Contraindicated after 8 yrs old

Osteotomies Toddlers & school-age During open reduction in a child >2 yrs with residual hip dysplasia Only after congruent reduction, satisfactory ROM, reasonable femoral sphericity Pelvic - >4 yo or severe acetabular side Femoral -


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Collapse Treatment:

Containment of the head Braces Surgical

Traction with pain and spasm Prognosis:

A self-limited disease Partial involvement better than complete involvement Younger age better than older age

COXA VARA AND VALGA Coxa vara

Decrease in the neck-shaft angle Shortened limb Limits hip abduction Types:

Congenitial Acquired

Common: trauma, LCPD, SCFE Coxa valga

Increase in the neck-shaft angle Normal in infants, decreases with weight bearing Seen in DDH and may be seen in lateral subluxation of the hip

CONGENITAL COXA VARA Generalities:

Evident once child is ambulatory Bilateral Cervical type Etiology:

Primary cartilaginous defect in the femoral neck Probably genetic

Clinical features: Lurching (unilateral) or waddling (bilateral) gait (+) Trendelenburg test Limited abduction and internal rotation Shortening of the limb

Radiographs: Decreased neck-shaft angle Triangular piece of bone in the femoral neck bounded by two radiolucent bands

Treatment: Surgery

Valgus osteotomy of the upper femur at the intertrochanteric or subtrochantericlevel

SCFE Generalities: Slipped capital femoral epiphysis Children 10-16 yrs, common in boys Contralateral hip involved 25% of the time Immediate cause is mechanical

Shearing stress is greater than resistance of the physis Slips mainly at hypertrophic zone

Four factors involved in pathogenesis: Increased height of the physis


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Alteration in the inclination angle of physis Abnormal loading of physis Insufficiency of tensile (collagen) and hydrostatic (proteoglycan) components of physis

Types: Acute slip

After severe trauma Acute on chronic

Sudden pain preceded by discomfort and limp Chronic

Slowly increasing symptoms Aching, fatigue, stiffness of hip, limp

Clinical features: Limb becomes shorter Limited ROM, especially IR and ABD Hip flexion results in obligatory abduction and external rotation Pain may be referred to the knee

Radiographs: Widening of the physis Lateral view shows posterior slip Chronic cases show bowed appearance of femoral neck and head

Radiographs: Degree of slip:

Preslipping wide physis Mild slip up to 1/3 the diameter of the neck Moderate up to 1/2 Severe greater than 1/2

Treatment: Traction for acute slips Surgery to stabilize the slip Corrective osteotomy

Complications: Osteonecrosis

Usually seen after manipulation or surgery

Chondrolysis Osteoarthritis

Prognosis: Good for mild slips treated early Severe slips are more prone to complications

BURSITIS Iliopectineal or iliopsoas bursa

Between iliopsoas and iliopectineal eminence Pain over middle of inguinal ligament Hip in flexion, abduction and external rotation Treated with rest, traction, warm compress

Deep trochanteric bursa

Between tendon of gluteus maximus and posterior aspect of greater trochanter LE in extension and external rotation with tenderness posterior to greater trochanter Superficial trochanteric bursa

Between the greater trochanter and the skin Pain on extreme hip adduction

Ischiogluteal bursa Superficial to the ischial tuberosity weavers bottom After prolonged sitting upon hard surfaces Pain may radiate along hamstrings


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HAMSTRING ORIGIN TENDINOPATHY Description:

Due to an acute tear that is not properly treated or as a result of overuse Usually involves the hamstring origin near the ischial tuberosity May be confused with an ischiogluteal bursitis

Signs and Symptoms: Sudden or insidious pain Tenderness over the involved area that is worsened by stretching the hamstrings or

resisting its contraction Treatment:

Deep transverse friction massage NSAIDs

ADDUCTOR TENDINOPATHY Description:

May occur secondary to an adductor muscle strain that is inadequately treated Signs and Symptoms:

Proximal groin pain Tenderness over the adductor origin and the pubic tubercle Pain on passive hip abduction and resisted hip adduction

Treatment: Rest NSAIDs Steroid injection

SNAPPING HIP SYNDROME Description:

There is a snap that may be felt or heard from the hip joint Snap from the lateral aspect of the hip is usually due to fibers of the tensor fascia lata or

the hip abductors as they slide over the greater trochanter Snap from the anterior of the hip is due to the psoas tendon as it passes over the hip joint

Signs and Symptoms: A snap may be heard with certain movements of the hip

Treatment: Reassurance Stretching of tight structures (e.g., hip flexors or abductors) If there is associated pain, NSAIDs may be given

Knee

MENISCAL INJURIES Generalities:

Crescent-shaped; wedge-shaped Outer one fourth is vascularized Functions:

Weight bearing Improves congruity of joint

Participates in rotary stability Generalities: Injured when trapped between condyles Medial meniscus injury more common Longitudinal split is the most common type

Clinical features: Pain after twisting a partially flexed knee Swelling Locking Joint line tenderness


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Clicking Thigh atrophy (+) McMurray or Appley test

Radiogrphy: Double contrast arthrography MRI

Treatment: RICE Unlock a lock knee Aspiration PT Arthroscopic surgery

MEDIAL COMPLEX INJURIES Generalities:

Valgus force on knee Injury may involve:

Superficial tibial collateral ligament Deep tibial collateral ligament Posterior oblique ligament Posterior medial capsule (hyperextension or external rotation of tibia) Cruciate ligaments

MEDIAL COLLATERAL LIGAMENT Valgus restraint Secondary restraints

Posteromedial capsule PCL ACL Semimembranosus

MEDIAL COMPLEX INJURIES Clinical features:

Pain and swelling Medial knee tenderness

Valgus stress test Mild: 10mm

Treatment: RICE Immobilization or controlled mobilization Surgery

LATERAL COMPLEX INJURIES Generalities:

Varus force on knee Less common than medial injuries

Injury may involve: Fibular collateral ligament Iliotibial band Lateral capsule Arcuate and posterior capsular structures Cruciate ligaments (PCL with knee flexed) Biceps tendon

LATERAL COLLATERAL LIGAMENT Varus restraint Secondary restraints


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Posterolateral capsule Iliotibial band Biceps femoris PCL ACL

LATERAL COMPLEX INJURIES Clinical features:

Pain and swelling Lateral knee tenderness Varus stress test

Mild: 10mm

Check function of the common peroneal nerve Treatment:

RICE Immobilization or controlled mobilization Surgery

ACL INJURIES Generalities:

Common Due to:

Extreme varus or valgus stress Hyperextension Rotation

May be associated with meniscal tears Clinical features:

Pain and swelling A pop is heard or felt Difficult ambulation Unstable knee (+) Lachman, anterior drawer and pivot shift tests

Treatment: Conservative Surgical

PCL INJURIES Generalities:

Due to: Extreme varus of valgus stresses Force applied anterior to tibia forcing it posteriorly

Clinical features: Pain and swelling A pop is heard or felt Difficult ambulation

(+) reverse Lachman, posterior drawer and sag sign Treatment: Conservative Surgical

OSGOOD-SCHLATTER DISEASE Generalities:

Partial separation of the epiphysis of the tibial tuberosity Due to sudden or continued strain Common in active boys, 10-14 yrs old


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Bilateral Clinical features:

Pain over the tibial tuberosity Enlarged and tender tuberosity Pain worse with stairs and running

Radiographs: Irregularity with slight separation of the tibial tuberosity epiphysis Fragmentation

Treatment: Restriction of activity Brace, splints, cast for 5 weeks Excision of bone fragments

RECURRENT PATELLAR INSTABILITY Generalities:

May be dislocation or subluxation Etiology:

Hypoplasia Patella alta Genu valgum, external tibial torsion Joint laxity

Glancing blow or contraction of quads with leg in ER may precipitate this Clinical features:

Pain and swelling Deformity Sense of instability Tenderness of medial border of patella Abnormal patellar tracking (+) apprehension test Q angle > 15 degrees

Treatment: Strengthen vastus medialis Bracing or taping

Surgery

CHONDROMALACIA OF THE PATELLA Generalities:

Degenerative condition of the cartilage Mainly young females Cartilage appears:

Dull and soft Fibrillated Fissured Eroded

Clinical features: Pain worse with resisted extension

Catching feeling Weakness of the knee Tenderness with pressure on patella Crepitation

Treatment: Rest Physical therapy Surgery

RUPTURE OF THE EXTENSOR MECHANISM


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Usually through the patella Avulsion of the rectus femoris

From AIIS Sharp hip pain worse with rectus femoris stretch Treated conservatively

Rutpure of the quads Due to stretch plus direct trauma Severe thigh pain and swelling Treatment may involve surgery

Rupture of the quadriceps tendon Due to degenerative tendon changes Older individuals Surgical

Rupture of the patellar ligament Rare Risk if steroid injected in the area Surgical

BURSITIS Generalities:

Several bursae around the knee: Prepatellar bursa Deep infrapatellar bursa Superficial pretibial bursa Popliteal bursa Anserine bursa

Trauma or strain may cause symptoms Generalities:

Prepatellar bursa Housemaids or nuns knee May get infected

Deep infrapatellar bursa Swelling leads to loss of parapatellar depressions

Popliteal bursa Gastrocnemiosemimembranosus bursa Bakers cyst

Clinical features: Swelling Pain

Treatment: Rest Warm compress Surgery

GENU VARUM Generalities:

Bowleg Seen upto 24 months old Etiology:

Rickets Blounts disease Bone dysplasias Trauma Arthritis Internal tibial torsion

Clinical features:


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Bowleg Pain and disability

If with arthritis Treatment:

Physiologic genu varum: reassurance Correct underlying disorders Surgery such as corrective osteotomy

BLOUNTS DISEASE Generalities:

Tibia vara Due to growth retardation at the medial proximal tibial physis From 1-3 years of age, usually bilateral

Clinical features: Bowleg

Treatment: Surgery

GENU VALGUM Generalities:

Knock-knee Etiology:

Physiologic between 2-4 years of age Rickets Bone dysplasias Trauma Arthritis

Clinical features: Knee valgus Pain in the presence of arthritis

Treatment: Treat any underlying disorder Surgery in the form of an osteotomy

PELLEGRINI-STIEDA DISEASE Generalities:

Ossification of the MCL Usually overlie the medial femoral condyle Usually males, 25-40 years old Trauma may be a causative factor

Clinical features: Medial knee is sensitive to pressure Ends of ROM are painful Swelling of the knee

Treatment: RICE

PTArthroplasty

ARTHROPLASTYo Operation to restore motion to a joint and function to the muscles, ligaments, and other soft tissue

structures that control the joint Resection arthroplasty Interpositional arthroplasty

y Autogenous tissuey Man-made substances


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Hemiarthroplasty Total joint replacement arthroplasty

GOALS To relieve pain To provide motion with stability To correct deformity

INDICATIONS Painful, disabling, arthritic joint not responsive to nonsurgical treatment Multiple joint involvement from a systemic illness

CONTRAINDICATIONS Absolute

y Recent or current joint sepsisy Neuropathic arthropathy

Relativey Several (e.g., poor medical condition, insufficient muscles to control the joint, etc)

MATERIALS Metals Ceramics Ultrahigh molecular weight polyethylene

TYPES OF FIXATION Bone cement Bone cement Press-fit fixation

y Porous coated materialsy Coating with calcium phosphate

COMPLICATIONS Medical complications

y Cardiac problemsy Thrombophlebitisy Pulmonary emboli

Mechanical complicationsy Implant breakagey Implant weary Implant loosening the most common long-term complication

Infection the most devastating and dreaded complication

TOTAL HIP REPLACEMENT ARTHROPLASTY INDICATIONS

y Alleviation of incapacitating pain not relieved by other meansy Improvement of hip functiony Reconstruction after excision of certain tumorsy Failed reconstructions (e.g., osteotomy)y Joint arthritis due to RA, DDH, osteonecrosisy Young patients with significant back or iipsilateral knee DJD who have an

indication for replacement

CONTRAINDICATIONSy Active infectiony Neuropathic jointy Processes that rapidly destroy boney Insufficient abductor musculaturey Progressive neurologic disease

COMPONENTSy Femoral stemy Femoral head


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y Acetabular component metal backingy Acetabular component polyethylene liner

COMPLICATIONSy Nerve injuriesy Vascular injuriesy Hemorrhage

y UTIy Hematomasy Limb-length discrepanciesy Dislocation and subluxationsy Heterotopic ossificationy Thromboembolismy Fracturesy Trochanteric nonunion and migrationy Looseningy Infectiony Osteolysis

UNIPOLAR PROSTHESIS One center of rotation Indications:

y Elderly patients with fractures of the neck of the femur that preclude internalfixation

y Femoral neck fractures with poor bone stock

BIPOLAR PROSTHESIS Decreases acetabular wear due to two centers of rotation Indications:

y Femoral neck fractures in active elderlyy Selected patients with AVN or OAy Salvage procedure in the face of massive acetabular deficienciesy Hip instability due to abductor deficiency

PT ASPECTSo Assessment:

General functional ability Compensatory patterns used to attain functionality Presence of factors that may make post-op rehabilitation difficult Leg length determination Hip ROM and strength of hip muscles

o Note: remember that the findings will change after surgeryo Postoperative care

Avoid positions of dislocation for 6 weeks:y Capsule opened anteriorly: hip dislocates in extreme extension, external rotation,

and adductiony Capsule opened posteriorly: hip dislocates in extreme flexion, internal rotation,

and adduction Regarding weight bearing:

y Cemented prosthesis: FWB is allowed immediatelyy Uncemented prosthesis: NWB or PWB for at least 6 weeks

Measure leg lengths and treat as needed Goals of postoperative treatment:

y Restore joint ROM (especially extension, abduction, and rotation)y Restore muscle strengthy Maintain or improve respiratory function


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y Maintain or improve venous return from the limby Patient education

Activities to avoid for the next 6 weeks:y Sitting with hips flexed more than 90 degreesy Bending forward to put shoesy Crossing legs

y Runningy Jumping

Preferred sports: low impact, non-contact sports

TOTAL KNEE REPLACEMENT ARTHROPLASTY INDICATIONS

y Relief of pain (e.g., in RA, OA )y Provide motion with stabilityy Correct deformity

CONTRAINDICATIONSy Recent or current joint sepsisy Neuropathic arthropathyy Poor general healthy Severe osteoporosis

TYPES OF KNEE JOINTy Unconstrainedy Semiconstrainedy Fully constrained

COMPONENTSy Femoral componenty Tibial trayy Tibial articular surfacey Patellar articular surfacey Thrombosis and thromboembolismy Poor wound healingy Infectiony Joint instabilityy Fracturesy Patellar tendon rupturesy Peroneal nerve injuryy Patellar problemsy Component looseningy Wear and deformationy Component breakage

PT ASPECTS Preoperative Care

y Isometric quad exercisesy Practice using walking aids if these will be needed postoperatively

Postoperative Carey Start isometrics of limb muscles and active foot pumpsy Active assisted knee flexion exercises once cleared to do thisy Aim for 70 degrees of knee flexion by day 7 postoperatively and 90 degrees by

day 14 postoperativelyy Walker ambulation for 6 weeks, then cane ambulation thereafter. Aim for

resuming normal activities by 10 12 weeks.y Functional rehabilitation such as stair climbing, sitting to standing, etc.y Avoid avoid any impact sports or activities that require squatting or kneeling


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Ankle & Foot FOOT STRAIN Generalities:

Common Due to excessive and unaccustomed standing and walking

Clinical features: Pain and tenderness of the longitudinal arch Chronic form fatigue and aching of the arch Tenderness beneath the navicular bone

Treatment: PT Arch support Shoe modification

FLEXIBLE FLATFOOT Generalities:

Loss of medial arch In children up to 5 years old Associated with heel eversion

Clinical features: Absence of arch Heel eversion Forefoot abduction ROM and MMT are normal Degenerative joint changes in adults

Treatment: Reassurance Shoe modification

PERONEAL SPASTIC FLATFOOT Generalities:

Peroneal spasm due to: Tarsal coalition

Arthritis Pain noted with weight bearing Secondary bone changes usually involving the talonavicular joint

Clinical features: Pronation with restricted subtalar inversion Pain Tenderness over peroneal tendons worse with inversion Antalgic gait

Treatment: Rest Supportive shoes Short leg walking cast for 4 weeks Surgery

Arthrodesis Excision of bar

CLAWFOOT Generalities:

Pes cavus with claw toes Plantar fascia is contracted Loss of normal elasticity of the arches Etiology:

Nervous system disorders (e.g. polio)


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Compartment syndrome Idiopathic

Clinical features: Deformity Early fatigue Calluses

Treatment: Stretch plantar fascia and Tendo-Achilles Shoe modification Surgery

Releases Tendon transfers Arthrodesis

KHLERS DISEASE Generalities:

Osteonecrosis of the navicular bone Starts at 6-9 yrs of age Idiopathic Trauma may be a factor Spontaneous recovery

Clinical features: Limp Tenderness and swelling over navicular bone Radiographs show small, dense and irregular bone

Treatment: Protection support arch and restrict activity Cast immobilization

METATARSALGIA Generalities:

Pain in the region of the metatarsal heads Over 30 yrs old, common in women

Common in: Everted or abducted foot Tight tendo-Achilles High-arched foot Claw toes High-heels, tight shoes

Clinical features: Pain under the middle metatarsal heads

Burning or cramping Worse with standing or walking

Tender callus under the involved head Treatment:

Shoe modification

Warm soaks Foot exercises Treatment of plantar warts Surgery

MORTONS NEUROMA Generalities:

Thickening of the common digital nerve at its bifurcation in the web space Due to repeated trauma of the nerve between the metatarsal heads Commonly involves 3rd web space followed by the 2nd web space


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Clinical features: Localized sharp or burning pain with radiation to the adjacent toes Paresthesia or numbness Localized area of tenderness Pain on squeezing the forefoot

Treatment: Metatarsal arch support Surgery

Excision of the enlarged segment

MARCH FRACTURE Generalities:

Stress fracture of metatarsal shaft, usually the 2nd or 3rd Metatarsus atavicus short 1st metatarsal

May predispose to march fracture Common in army recruits

Clinical features: Increasing pain Swelling Localized tenderness

Treatment: Rest Shoe modification Cast immobilization for 3-4 weeks

FREIBERGS DISEASE Generalities:

Osteonecrosis of a metatarsal head Degenerative changes usually involving the 2nd metatarsal head Trauma may play a role

Clinical features: Pain on weight bearing Thickening and tenderness of the affected head

Radiographs show bone resorption with deformity Treatment:

Plaster immobilization or anterior arch pad Surgery

Resection arthroplasty

HALLUX VALGUS Generalities:

Lateral angulation of the big toe at the metatarsophalangeal joint 1st metatarsal deviates medially while toe deviates laterally

Bunion bony prominence with overlying bursa Usually familial and in women Shoe wear may initiate the deformity

Clinical features: Deformity Widened forefoot Depressed metatarsal arch Big toe pronates

Overlapping toes Pain

Arthritis Bursitis Nerve compression


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Treatment: Properly fitting shoes Stretching Treatment of bursitis Surgery

HALLUX VARUS Generalities:

Medial angulation of the big toe at the metatarsophalangeal joint Due to:

Congenital Trauma Muscle imbalance Iatrogenic

Clinical features: Deformity Pain

Treatment: Surgery

HALLUX RIGIDUS Generalities:

Degenerative joint disease of the 1st metatarsophalangeal joint Clinical features:

Limited ROM, especially dorsiflexion Burning or throbbing pain

Treatment: Shoe modification

Inflexible sole Metatarsal bar

Surgery Cheilectomy Arthrodesis

LESSER TOE DEFORMITIES Hammer toe

Dorsiflexion of the MTP joint and plantar flexion of the PIP joint Usually 2nd toe

Clawtoe Hyperextension of the MTP joint and flexion of the IP joints

Mallet toe Flexion contracture of the DIP joint

Clinical features: Deformity Calluses and corns Pain

Treatment: Manipulation and splinting Shoe modification Surgery

IN-TOEING Generalities:

Pigeon toe Feet turn in when walking Due to:


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Feet metatarsus varus, hallux varus, clubfoot Leg bowlegs, medial tibial torsion Hip anteversion, tight IR

Clinical features: Deformity

Dependent on the site of abnormality Treatment:

Spontaneous correction Denis Browne night splint Surgery

OUT-TOEING Generalities:

Due to: Feet forefoot abduction Leg external tibial torsion Hip retroversion, tight ER

Clinical features: Deformity

Treatment: Correct flatfoot Denis Browne splint

ACHILLES TENDINITIS Generalities:

Inflammation of tendo-Achilles In 2 areas:

At insertion Insertional tendinitis

4-6 cm proximal to insertion Predisposes to rupture

Peritendinitis that may progress to a tendinosis Clinical features:

Pain 4-6 cm proximal to insertion At insertion to calcaneus

Swelling Pain aggravated by dorsiflexion

Treatment: Rest Heat Heel elevation Immobilization

BURSITIS Generalities:

Inflammation of a bursa May involve: Retrocalcaneal bursa

Haglund deformity (pump bump) may be noted Superficial calcaneal or posterior Achilles bursa

Clinical features: Pain Local tenderness Swelling

Treatment:


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Rest Heat Heel elevation Surgery

Excision of bursa

SEVERS DISEASE Generalities:

Osteochondrosis of the posterior calcaneal apophysis Believed to be due to inflammation of surrounding soft tissues Ages 7 10 yrs

Clinical features: Pain in the posterior heel

Worse with activities Swelling Erythema Radiographically, apophysis is sclerotic and irregular

Treatment: Rest Stretching Heel lift Walking cast for 6 weeks

TENDO-ACHILLES RUPTURE Generalities:

Chronic Achilles tendinitis may be a factor May be partial or complete Diagnosis may be missed since there are other plantarflexors of the ankle joint

Clinical Features: Pop Pain Swelling Limp

Simons sign palpable defect Positive Thompson test Ecchymosis

Treatment: Casting Surgery

PERONEAL TENDON SUBLUXATION Generalities:

Peroneal tendons are retained in place by: Superior peroneal retinaculum Inferior peroneal retinaculum

Rupture leads to subluxation or dislocation

Often due to trauma Clinical Features: Displacement with active dorsiflexion and eversion Pain

Treatment: Immobilization

Acute cases Surgery

Chronic cases


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ANKLE SPRAIN Generalities:

Usually involves the anterior talofibular and/or the calcaneofibular ligament May be associated with fractures Usual mechanism of injury is inversion and plantarflexion

Clinical Features: Pain, tenderness and swelling over the lateral aspect of the ankle A crack or pop may be felt or heard

Treatment: RICE Crutches may be needed if there is difficulty bearing weight Rehabilitation

PLANTAR FASCIITIS Generalities:

Considered an overuse condition of the plantar fascia at its attachment to the calcaneus Commonly seen in activities requiring maximal plantarflexion of the ankle and dorsiflexion

of the metatarsophalangeal joint Clinical Features:

Pain in the inner aspect of the heel, worse after a period of non-weightbearing Tenderness on the medial aspect of the plantar surface of the heel Radiographs may show a calcaneal spur inferiorly

Treatment: Stretching of the plantar fascia and the gastroc-soleus muscles Use of heel cup NSAIDs

SHIN SPLINTS Generalities:

Overuse myositis May involve the tibialis posterior, tibialis anterior or peroneal muscle groups Rule out stress fracture of the tibia

Clinical Features:

Pain may have been present for a long time Pain may progress to the point that it occurs even with minimal exertion Area of maximal tenderness over the muscle tendon units involved

Treatment: RICE NSAIDs Deep massage therapy Correct anatomic variations of the foot

DIABETIC FOOT WOUND A variety of pathological conditions affecting the foot of a diabetic person. Includes:

Ulcers

Cellulitis Osteomyelitis COMPLICATIONS OF DM Peripheral Neuropathy

Ulcers Diabetic osteoarthropathy (neuropathic foot)

Peripheral vascular disease Chronic hypoxia causes poor wound healing Gangrene

PERIPHERAL NEUROPATHY


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Sensory neuropathy Cannot feel pain

Motor neuropathy Foot deformities

Autonomic neuropathy Dryness causes skin to crack Hyperkeratotic plaque AV shunting and edema

NEUROPATHIC FOOT Common patterns of collapse

Collapse in and around the navicular Collapse at Lisfranc joints

Collapse occurs distally (not at hindfoot): Intrinsic muscle weakness Weak ankle dorsiflexor

distal sensory neuropathy: CHARCOT FOOT AUTONOMIC NEUROPATHY MECHANISMS OF INJURY Tissue disruption Small force sustained over time Moderate force repeated over time Infection FOOT ULCERATION Risk factors:

Vascular insufficiency Peripheral neuropathy Stiffer skin Foot hygiene and footwear Diabetic control Previous ulcers

FOOT ULCERATION Risk factors (continued)

Foot deformities Increased body weight Past history of amputation Poor vision

FOOT ULCERATION Majority occur at or distal to the metatarsal heads

Intrinsic weakness causes clawing of toes Major cause:

Areas of increased pressure on insensate skin RISK FACTORS FOR AMPUTATION

Peripheral sensory neuropathy Foot ulcers Peripheral vascular disease

Former amputation Treatment with insulin

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Ortho Notes 2